Public Health Report : Tai Chi for Cardiovascular Disease
Author : Eric L. Zielinski
Cardiovascular disease (CVD) is the number one killer in the world and does not discriminate against age, race, gender or socio-economic background. Even amidst the billions spent on medical therapy, people are still dying at alarming rates. The world is desperate for alternative approaches as their very lives are dependent on it. Thankfully, there has been a surge of research linking proven techniques like Tai Chi and reduced CVD this past decade. This report highlights some of the details.
It is vital to mention that, according to the National Heart Lung and Blood Institute, a division of the U.S. Department of Health & Human Services, “The cause of atherosclerosis is not known.” Current prevailing thought, however, is that inflammation is responsible via oxidative stress. This is suspected to cause the atherosclerotic plaquing that has become as characteristically accepted as the primary cause of CVD. The question that scientists have debated, however, is what exactly causes the inflammation? Many blame cholesterol, but the growing body of evidence supports that physical and psychological stress – a proven lead contributor to inflammation – are the main causes of heart disease.
According to the World Health Organization (WHO), stress-related behavioral risk factors are responsible for about 80 percent of coronary heart disease and cerebrovascular disease. Behavioral risk factors include smoking, unhealthy diet, physical inactivity and poor sleep quality. Consequently, affected individuals present with raised blood glucose, raised blood lipids, raised blood pressure, and the onset of obesity. These are called “intermediate risk factors” or “metabolic risk factors.”
Shockingly, there are often no symptoms preceding CVD. The first warning sign is oftentimes a heart attack or stroke, giving the victim little to no time to react and make the necessary changes to amend their lifestyle. According to the WHO, “Individuals can reduce their risk of CVD by engaging in regular physical activity, avoiding tobacco use and second-hand tobacco smoke, choosing a diet rich in fruit and vegetables and avoiding foods that are high in fat, sugar and salt, and maintaining a healthy body weight.”
The initial global approach to manage CVD via altering diet and exercise is relatively inexpensive. Although, if diet and exercise do not correct the problem, more costly measures like drugs and surgery are usually implemented. Subsequently, an exorbitant economic burden has overtaken our global bottom-line as a result of CVD treatment. These interventions have cast hundreds of billions of dollars upon health care expenditures across the globe and are growing exponentially. For instance, the IMS Institute For Healthcare Informatics reported that spending on cholesterol-lowering drugs increased by $160 million in 2010 alone. More than 255 million prescriptions were issued for these drugs in 2010, making them the most commonly prescribed medication in the U.S.
It is important to note that patients with high cholesterol are oftentimes treated via “combination therapy,” in which drug combinations are employed at lower dosages than needed if used singly. For example, it is documented that cholesterol-lowering statins combined with ezetimibe, niacin, or a bile acid sequestrant can reduce blood cholesterol levels by 50 percent. Vytorin, a preparation of simvastatin combined with ezetimibe, is purported to lower LDL levels by 60 percent.
Although, believed to reduce CVD risk factors, when a cocktail of pharmaceuticals are mixed together like this, the side effects become very complicated and oftentimes miserable for the patient to endure. They can even lead to death. Subsequently, many people are taking great strides to get off these medications. This may prove to position Tai Chi as a sought-after approach as people seek drugless alternatives.
If pharmaceutical management is unsuccessful, then physicians may take more invasive approaches. In the U.S. alone, more than 1.5 million angioplasties and coronary bypass surgeries are performed each year, making heart surgery one of the most commonly performed surgical procedures for both men and women. The economic burden due to these interventions is staggering well into the billions annually. Based on the faulted logic that clogged arteries are seen as analogous to clogged drainpipes, which need a simple, easy “snake” to clean out the sludge, angioplasty simply do not work that way. If the “snaking” doesn’t work, it is believed that adding a new pipe (bypass surgery) should keep blood flow regulated. Michael Ozner, MD contends that, “Although heart surgery can be lifesaving, the truth is that surgery benefits only a small fraction of the millions of patients who undergo these operations…In fact, except for a minority of patients, bypass surgery and angioplasty have never been shown to prolong life or prevent heart attacks.” He reports that 70 – 90 percent of heart surgeries are unnecessary.
The crux of this entire discussion is that in spite of the billions of dollars that are spent on various drugs and surgeries to treat CVD, these interventions are proving quite ineffective. Death tolls continue to climb globally and this happens directly in the face of the measures discussed above to prevent or treat them. The world is looking for treatment options that are not only more cost-effective, but actually work. It appears quite possible that alternative approaches like Tai Chi can rise up and answer this call.
The research linking Tai Chi and decreased CVD risk factors and/or symptoms of heart disease is richly abundant. In the review below, note Tai Chi’s ability to prevent or manage related issues such as high blood pressure, stress, depression, anxiety, obesity, inflammation, increased hormones, lack of exercise, and others.
• To compare studies targeting Tai Chi and Qigong and identify the physical and psychological health outcomes shown to be associated with them in adults older than 55, University of Arizona and Arizona State researchers evaluated 36 research reports with a total of 3,799 participants and observed the following: “Significant improvement in clusters of similar outcomes indicated interventions utilizing [Tai Chi and Qigong] may help older adults improve physical function and reduce blood pressure, fall risk, and depression and anxiety. However, as researchers indicated, “Missing from the reviewed reports is a discussion of how spiritual exploration with meditative forms of [physical activity], an important component of these movement activities, may contribute to successful aging.” It would be interesting to discover how the spiritual component of Tai Chi contributes to these statistics and, therefore, learn how to enhance their experience to maximize the heart benefits.
• In 2004, the American Journal of Medicine published a Harvard Medical School study where researchers examined the effects of a 12-week Tai Chi program on quality of life and exercise capacity in patients with heart failure. According to the researchers, “At 12 weeks, patients in the Tai Chi group showed improved quality-of-life scores, increased distance walked in 6 minutes and decreased serum B-type natriuretic peptide levels compared with patients in the control group. As a neurohormone secreted by the ventricles indicating volume expansion and pressure overload, it has been proven that serum levels of the cardiac neurohormone B-type natriuretic peptide can predict mortality in patients with acute coronary syndromes. Consequently, this study is paramount in showing Tai Chi’s effectiveness in helping prevent heart failure.
• The American Journal of Medicine published a Harvard Medical School in 2004 that examined the effects of a 12-week Tai Chi program on quality of life and exercise capacity in patients with heart failure. Thirty patients of the average age of 64 years were recruited because they had chronic stable heart failure and left ventricular ejection fraction. Fifteen were randomly assigned to receive usual care, which included pharmacologic therapy and dietary and exercise counseling and 15 were assigned to participate in 12 weeks of Tai Chi training twice a week for one-hour sessions in addition to usual care. Secondary outcomes included serum B-type natriuretic peptide, and plasma catecholamine levels (hormones produced by the kidneys and indicate high levels of stress such as dopamine, norepinephrine, and epinephrine). According to the data, “At 12 weeks, patients in the Tai Chi group showed improved quality-of-life scores, increased distance walked in 6 minutes (135 meters), and decreased serum B-type natriuretic peptide levels (-138 pg/mL) compared with patients in the control group. A trend towards improvement was seen in peak oxygen uptake. No differences were detected in catecholamine levels.” Like the study above, the like between falling serum B-type natriuretic peptide levels, Tai Chi and decreased risk for CVD cannot be stressed enough.
• Research has also proven that Tai Chi can help improve sleep quality even amongst people with chronic heart failure. Printed in Medicine and Sport Science in 2008, Harvard Medical School researchers took 30 people with chronic heart failure and split them into two groups: one in which volunteers actively participated in a 12-week Tai Chi program and continued usual medical care; and one group in which they continued usual medical care only. The results evaluated the following: quality of life, exercise capacity, B-type natriuretic peptide, catecholamine levels, heart rate variability, and sleep stability. To determine quality of life the Minnesota Living With Heart Failure Ò Questionnaire was used – containing 21 questions with possible answers ranging from 0 to 5; the higher the score the worse the quality of life reported with 105 being the highest score possible. According to the study, the Tai Chi group reported fantastic results including: improved quality of life, increased exercise capacity via 6-minute walk test, and decreased B-type natriuretic peptide in comparison to the control group. In addition, those in the Tai Chi group experienced a significant increase in sleep quality as measured by an increase in high-frequency coupling and a reduction of low-frequency coupling in comparison to the control group.
• A 2009 pilot study was printed in the Clinic Journal of Sport Medicine reporting the effects a 10-week multidisciplinary Tai Chi intervention had on 21 sedentary obese women. At the time of publication, this was the first study to evaluate these factors as most research designs have concentrated on diet and conventional exercise programs; thus, neglecting the mind-body aspect. As part of the design, participants added Tai Chi to their regular care plan, which included the following: a low calorie diet; weekly group sessions meeting with their physician, psychologist, and dietician; and a generic exercise program. Changes in weight, body composition, heart rate, blood pressure, mobility scores, mood, Three Factor Eating Questionnaire scores, and General Self-Efficacy were looked at carefully. The Tai Group “improved in resting systolic blood pressure, chair rise test, mood, and reduced percent of fat at week 10 and at 6 months follow-up. General self-efficacy was enhanced in both groups and maintained at 30 weeks;” thus, highlighting Tai Chi’s longstanding effects on people even after 20 weeks of discontinued use.
• In 2010, BMC Complementary and Alternative Medicine published an article from Tufts University School of Medicine researchers that systematically reviewed the effects of Tai Chi on stress, anxiety, depression and mood disturbance in eastern and western populations. In total, of the 29 articles they found, they evaluated 19 studies highlighting the anxiety-reducing ability of Tai Chi. Of significant interest is an eight-study group reflecting data from 359 participants with “symptomatic osteoarthritis, healthy adults, elderly with cardiovascular disease risk factors, individuals with fibromyalgia, and adolescents with ADHD found that Tai Chi practiced 2 to 4 times a week (30 to 60 minutes per session) for 5 to 24 weeks was associated with a significant reduction in anxiety.” For one activity (i.e. Tai Chi) to affect this dangerous risk factor (anxiety) in such a wide variety of health concerns points to the unbelievable, global benefits Tai Chi has on the body. This fact cannot be stressed enough as there are not many things that can do this!
• Unlike the scores of research proving that strenuous, exhaustive exercises cause short-term immune suppression, limited studies have been conducted on why so many people report beneficial effects on their immune systems after practicing Tai Chi. Subsequently, researchers from Chang Gung Memorial Hospital–Kaohsiung Medical Center set out to determine which health benefits are specifically affected and which biomarkers are responsible for this phenomenon. The study, published in Clinical Chemistry in 2010, investigated serum proteomic markers – blood markers indicating the full set of proteins encoded by a genome – to determine this. In all, the researchers, “Identified 39 protein spots for 18 proteins with a noticeable increase or decrease after [Tai Chi] exercise. Validation of the differentially displayed proteins with 20 paired pre- and post-exercise samples revealed a significant increase in complement factor H associated with decreases in C1 esterase inhibitor and complement factor B.” They concluded, “In this first study of proteomic biomarkers of [Tai Chi] exercise, we found an increase in complement factor H associated with a decrease in complement factor B.” In effect, since complement factor H is known for its ability to protect the body from microangiopathy [microvascular disease, or small vessel disease] and macular degeneration, Tai Chi was proven to increase specific immune responses thereby reducing someone’s risk for heart and eye disease.
• The journal Work, printed an article praising Tai Chi for being a “simple, convenient workplace intervention that may promote musculoskeletal health without special equipment or showering.” This fact is oftentimes overlooked as workers will generally not take time to exercise because of the time it takes to set up, break down, clean up, or walk/drive to the gym. Fifty-two people volunteered for a 12-week program where they practiced Tai Chi twice a week for 50 minutes per session during their lunch hour. In regards to CVD risk factors, York University researchers discovered that “there were significant positive results in several areas including resting heart rate, waist circumference and hand grip strength. Results showed that the [Tai Chi] program was effective in improving musculoskeletal fitness and psychological well-being.” Directly addressing the concern many people have about not being able to exercise at work, the article concluded, “Significant improvements in physiological and psychological measures were observed, even at the large class sizes tested here, suggesting that [Tai Chi] has considerable potential as an economic, effective and convenient workplace intervention.”
• In 2011, the Japanese Journal of Geriatrics published a study in which Department of Public Health, Fukushima Medical University researchers recruited elderly individuals at least 65 year old that had experienced a fall in the past year, yet were not receiving long-term care for their injury. Thirty-four people were selected to participate in a once-per-week, 15-week Tai Chi program, and 84 were selected to be part of the control group. Fascinatingly, only two participants (6.3 percent) in the Tai Chi group ultimately were determined to require long-term care where 19 (24.1 percent) of the participants who did not practice Tai Chi for the 15 weeks required the care-need certification. In addition, researchers “observed significant changes between pre- and post-intervention on several variables, including motor fitness scale, maximum walking speed over 10 meters, functional reach test, ability to stand after a long period of sitting, and maximum one step width.” There were no significant differences in the number of deaths between the two groups. Thus, researchers were confident to conclude that, “The Tai Chi exercise based intervention program for frail elderly people reduced the need for new care-need certification and was useful as a care prevention program.” Subsequently – as it has been proven by an article published in the British Medical Journal that slow walking speed in elderly individuals is “strongly associated with an increased risk of cardiovascular mortality” – Tai Chi’s ability to help prevent heart disease is all the more clear.
• The American Journal of Geriatric Psychiatry printed a study in 2011 that reports the results of UCLA researchers determining to see whether Tai Chi could change the treatment plan of depressed elderly to achieve a decrease in symptoms and improvement in health functioning and mental performance. One hundred twelve adults age 60 years and older with diagnosed depression were recruited and treated with an anti-depressant drug (escitalopram) for approximately four weeks. Of those who responded to escitalopram (73 people), they continued to receive escitalopram daily and were randomly assigned to either 10 weeks of Tai Chi or health education for 2 hours per week. After 14 weeks of follow-up, researchers were able to confidently determine that, “Subjects in the escitalopram and [Tai Chi] condition were more likely to show greater reduction of depressive symptoms and to achieve a depression remission as compared with those receiving escitalopram and [health education]. Subjects in the escitalopram and [Tai Chi] condition also showed significantly greater improvements in 36-Item Short Form Health Survey physical functioning and cognitive tests and a decline in the inflammatory marker, C-reactive protein, compared with the control group.” As CVD is primarily an inflammatory disorder, this study highlights the link between Tai Chi and CVD prevention. Further research is needed to prove the exact mechanisms as to why this occurs, as the medical community is still skeptical of recommending Tai Chi for all their patients for CVD prevention and management.
• The American Journal of Geriatric Psychiatry printed a study in 2012 that reports the results of UCLA researchers evaluating the effects Tai Chi has on markers of inflammation in older adults. Of the total of 83 healthy older adults, aged 59 to 86 years who participated, some were randomly selected to be part of a 16-week group Tai Chi program and others selected to be part of a control arm in which they experienced group health education. The primary data collected was circulating levels of interleukin 6 (IL-6) – an immune response heavily involved in the natural inflammatory process that indicates risk for heart disease. Secondary outcome measures evaluated were similar types of inflammatory markers: C-reactive protein, soluble IL-1 receptor antagonist, soluble IL-6 receptor, soluble intercellular adhesion molecule, and IL-18. In addition, severity of depression symptoms, sleep quality, and physical activity was also assessed over the treatment trial. The results were astonishing and highlight Tai Chi’s ability to help regulate the entire body and not just in regards to CVD. Not only was it reported that the Tai Chi group had greater drops in IL-6 than the control group, those with the highest IL-6 at the beginning of the study (and thereby were most at risk of a heart attack) experienced the greatest decline. In addition, the volunteers also experienced decreased depression symptoms that the researchers linked to the drop in IL-6. In summary, the researchers concluded, “[Tai Chi] can be considered a useful behavioral intervention to reduce circulating levels of IL-6 in older adults who show elevated levels of this inflammatory marker and are at risk for inflammation-related morbidity.”
• To test the hypothesis that Tai Chi is a reliable method for relieving the side effects of conventional cancer treatments in breast cancers survivors, earlier this year University of Hong Kong researchers investigated the effects of Qigong exercise on upper limb lymphedema, arterial resistance, and blood flow velocity in survivors with breast cancer and mastectomy. Eleven breast cancer survivors with Tai Chi-type Qigong experience were assigned to the experimental group and 12 survivors of breast cancer without Qigong experience were assigned to the control group. With the average age of 58 and 54 years, respectively, everyone in both groups had breast cancer-related lymphedema. All procedures were completed within one session and the experimental group performed 18 Forms Tai Chi Internal Qigong for approximately 6 minutes while the control group rested for similar duration in a sitting position. Every participant had their affected upper limb circumference measured by using tape measures. In addition, their peripheral arterial resistance and blood flow velocities were evaluated using a Doppler ultrasound machine. Astoundingly, the circumferences of the affected upper arm, elbow, forearm and wrist decreased after Tai Chi. Regarding vascular outcomes, the resistance index decreased and the maximum systolic arterial blood flow velocity and minimum diastolic arterial blood flow velocity increased significantly after Tai Chi. Researchers concluded, therefore, that “Qigong exercise could reduce conventional cancer therapy side effects such as upper limb lymphedema and poor circulatory status in survivors of breast cancer. However, such effects may be temporary, and further studies must be conducted to explore longer term effects.”
• This past February, The Journal of Nursing reviewed the effects Tai Chi has on blood pressure, blood sugar and blood lipid control for patients with chronic diseases. By reviewing six electronic databases for related articles published between 1990 and 2011, Chang Gung University of Science and Technology researchers were able to collect seven studies in which 947 people participated in clinical trials. They concluded that risk factors leading to CVD were minimized by Tai Chi and stated the ”systematic review results indicate that Tai Chi interventions have a significant and positive effect on blood pressure and lipid levels.”
• This past March, a paper printed in American Journal of Health Promotion set out to determine the associations between Tai Chi, anxiety, and cardiovascular disease risk factors. One hundred thirty-three adults aged 55 years and older were recruited from a community in Taipei City, Taiwan and sixty-four volunteers attended a 60-minute Tai Chi exercise program three times per week for 12 weeks and 69 volunteers did not. Not only did the Tai Chi group show a greater drop in anxiety levels and diastolic blood pressure at the 12-week follow-up than did the control group, systolic diastolic blood pressure significantly decreased in the 6-week follow-up and 12-week follow-up tests. Furthermore, the Tai Chi achieved a greater drop in body mass index at the 6-week and 12-week follow-up visits than the controls, thus proving Tai Chi’s long-standing effects on people even after they discontinue the exercise. The researchers concluded, “The results highlight the long-term benefits of a [Tai Chi] program in facilitating health promotion by reducing anxiety and risk factors for cardiovascular diseases.”
The research on Tai Chi’s ability to prevent and treat CVD has blossomed the past decade and only promises to grow in the future. Hopefully, the medical community will embrace this ancient mind-body art form as an integral part of their CVD standard of care as it currently seen through skeptical lenses.
Currently, the debate to determine what exactly causes CVD has led scientists away from high fat and cholesterol diets to conclude that stress-related inflammatory and hormonal responses are key components to atherosclerotic plaque build-up and subsequent heart disease. Not surprisingly, a review of literature indicates that Tai Chi is effective in managing key risk factors associated with CVD due to its potential effect on inflammatory markers; namely, C-reactive protein (CRP), IL-6, immune system response(s), serum B-type natriuretic peptide levels, blood pressure, psychological and physiological stress. Therefore, it with great pleasure that we share the results of several clinical trials proving that alternative approaches like Tai Chi may not only prevent, but also manage heart disease.
BMC Complementary and Alternative Medicine
Evidence-Based Complementary and Alternative Medicine
American Journal of Medicine
The American Journal of Medicine
Medicine and Sport Science
Clinic Journal of Sport Medicine
The American Journal of Geriatric Psychiatry
The American Journal of Geriatric Psychiatry
Japanese Journal of Geriatrics
The Journal of Nursing
American Journal of Health Promotion
Public Health Report : Tai Chi for Cardiovascular Disease (CVD)
Author : Eric L. Zielinski